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In B.C., doctors’ billings have been public for decades. Transparency simply ‘part of our culture here,’ physician says

VANCOUVER—Nearly 50 years after British Columbia became the first province in Canada to make medical billings public, doctors here say having their billings published has had little to no impact on their lives or practice.

The “Blue Book,” or the Medical Services Commission Financial Statement, is an annual online listing of the names and total billings for every medical practitioner who bills B.C.’s fee-for-service health system more than $25,000 a year. It also lists the billings of organizations such as hospitals and clinics.

Dr. Kathleen Ross, president of Doctors of B.C. (formerly the B.C. Medical Association) and a physician of 26 years, told the Star transparency in billing is simply part of the job, and is not a “great concern” to doctors.

“I’ve never had any challenges with it,” said Ross, whose organization represents 14,000 physicians, residents and medical students in the province. “It’s part of our culture here. Transparency is a good thing. We respect the fact that the public has a right to know.”

It’s a different story in Ontario, where doctors’ billings have long been cloaked in secrecy and required a five-year battle by the Star to get access to the names of physicians who receive the most from the public purse.

Seven years of Ontario Ministry of Health data recently obtained by the Star identifies 194 doctors out of the 31,500 across the province whose annual billings to the Ontario Health Insurance Plan — from a high of around $6.9 million to a low of $1.4 million — placed them in the Top 100 at least once between 2011 and 2018. Nearly half are ophthalmologists or radiologists.

The quest to get the information began with a Freedom-of-Information request filed by health reporter Theresa Boyle in 2014 and ended in April, when the Supreme Court decided not to hear a final appeal from the Ontario Medical Association, which wanted the names kept secret.

The lack of transparency in Ontario stands in stark contrast to B.C., where billings have been publicly available for decades. In 1970, the Blue Book was introduced by then-B.C. premier W.A.C. Bennett just a few years after the province joined the federal medicare program. According to Dr. Brad Fritz, a physician and author of The BCMA, Then and Now, a book on the history of the British Columbia Medical Association, Bennett was concerned over the large portion of the budget that was going towards health care, and he created the Blue Book in an attempt to fuel public backlash over costly doctor payments.

But it had the opposite effect, eliciting concern over how little doctors at the time were paid.

“The number one fallout at that time, among people who bothered to look, was people saying to doctors, ‘Is that all you get paid?’ ” Fritz told the Star. “Compared to business people and lawyers, it wasn’t as much.”

Fritz said after nearly 50 years, there’s been “no negative” side to making billings transparent.

“I think it’s always good for people paid out of the public purse to be aware of what it’s costing the taxpayer.”

Based on the data from the most recent version of the Blue Book — for the 2017-18 fiscal year — the province spent just over $4.5 billion on billings from all listed physicians, health authorities and organizations, accounting for 23.7 per cent of the total health budget for that year.

Total billings for that year include 11,448 individual practitioners operating under the fee-for-service model, and more than 200 health organizations. The book does not include the small number of doctors who work on contract for a health authority or receive salaries and are not paid on a fee-for-service basis.

In the 2017-18 Blue Book, the highest billing by an individual doctor was listed at $3,360,965. Only two other doctors billed more than $3 million, with all three of the top billers being ophthalmologists. Another 20 doctors had billings in the $2 million range.

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The Blue Book does not list a doctor’s specialty or specific services billed, but Andrew Longhurst, research associate with the Canadian Centre for Policy Alternatives, cross-referenced Blue Book data with listings from B.C.’s College of Physicians and Surgeons and found that the highest payments went to doctors in ophthalmology, cardiology, orthopedic surgery and other high-volume procedure specialties.

According to the Canadian Institute for Health Information’s National Physician Database, the average gross clinical payment for a B.C. physician in 2016–17 (the most recent year available) was $289,971.

This is less than the national physician average of $342,228, and ranks as the third lowest average payment, after Newfoundland and the Yukon. (The Northwest Territories and Nova Scotia were not included in the data set.) Physicians in Alberta take home the highest payment, an average of $385,522. In Ontario, the average was $344,531.

The Blue Book notes gross payments do not account for a doctor’s overhead expenses — which can include costs for staff, rent and equipment — and it would be impossible for readers to glean a physician’s net income from the amounts listed.

“Conclusions cannot be drawn from these figures about the relative net income of any practitioner since overhead varies greatly from practitioner to practitioner,” the Blue Book states.

Ross, the president of Doctors of B.C., said it’s important for the public to know the Blue Book does not list take-home pay and that overhead costs can take up a significant portion of what is billed.

“The numbers recorded in the Blue Book don’t differentiate from what a physician bills and what they bring home,” she said. “Overhead can be up to 45 per cent of billings, or in the case of a high-cost practice such as ophthalmology, even higher.”

Dr. Owen Williamson, president of Pain Physicians of B.C. Society, said while the Blue Book does not account for overhead or the extra fees doctors pay to regulatory bodies such as the College of Physicians and Surgeons of B.C., it also does not account for additional payments doctors may receive, such as for elective procedures the province does not cover.

“People who get full or partial payment through alternative services, which are not covered under the province’s plan, they may appear to have a low income based on the Blue Book, but actually have more income based on those services,” he said.

However, Williamson said after decades of publication of the Blue Book, patients in B.C. are familiar with the information the book can — and cannot — provide.

“It’s been going on for a while, so the public has a sense of the limitations,” he said. “Most people realize that and it seems to be a non-issue.”

Williamson said the initial interest in the release of details of physician billings in Ontario would eventually “die down” after the public gets used to that level of transparency.

“Doctors fighting against it have given the whole thing too much oxygen.”

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